Provider Demographics
NPI:1013801661
Name:TYSON, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:TYSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 SCHOFIELD ST
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:KS
Mailing Address - Zip Code:66871-9723
Mailing Address - Country:US
Mailing Address - Phone:785-229-6845
Mailing Address - Fax:
Practice Address - Street 1:1649 61ST ST FL 3013
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-2110
Practice Address - Country:US
Practice Address - Phone:785-229-6845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-06
Last Update Date:2025-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician